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138th APHA Annual Meeting Denver, ColoradoNovember 8, 2010
Dennis P. Andrulis, PhD, MPHSenior Research Scientist, Texas Health InstituteAssociate Professor, University of Texas School of Public Health
Nadia J. Siddiqui, MPHSenior Health Policy Analyst, Texas Health Institute
Jonathan P. Purtle, MPH, MScProgram Manager, Drexel University School of Public Health
Click to edit Master title styleClick to edit Master title styleBackground and PurposeBackground and Purpose• With support from the Joint Center for Political and
Economic Studies, we conducted a comprehensive review of the Patient Protection and Affordable Care Act of 2010:
– To identify and describe provisions specific to race, ethnicity and language; and general provisions likely to have a significant affect on diverse populations.
– To assess status, challenges and opportunities of health care reform provisions for improving the health and health care of racially and ethnically diverse populations.
– To offer a template and user-friendly framework for documenting and tracking implementation timeline, appropriations and federal agency oversight responsibility.
Click to edit Master title styleClick to edit Master title styleFramework for ReviewFramework for Review
Race, Ethnicity and Language-Specific PrioritiesA. Data Collection and Reporting by Race, Ethnicity & Language
B. Workforce Diversity
C. Cultural Competence Education and Organizational Support
D. Health Disparities Research
E. Health Disparities Initiatives in Prevention
F. Addressing Health Disparities in Health Insurance Reforms
General PrioritiesA. Health Insurance Reform
B. Access to Health Care
C. Quality Improvement
D. Cost Containment
E. Public Health Initiatives
F. Social Determinants of Health
Review of provisions addressing 12 key public health, health care system and health disparities priorities.
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Click to edit Master title styleClick to edit Master title styleGeneral ProvisionsGeneral ProvisionsHealth Insurance Reforms Sec.
Require individual coverage 1501
Expand Medicaid income eligibility to 133% FPL
2001
Employer coverage requirement 1513
Increase federal matching rates for Medicaid
2005
Small business (<25 employees) tax credits
1421
Multi-state plan option 10104Temporary high risk pools 1101Consumer Operated and Oriented Plans (CO-OPs)
1322
State-based American Health Benefit Exchanges
1311
Improving Access to Care Sec.
Support for community health centers
10503
Nurse-managed health centers 5208
Community health teams 3502
Redistribute Graduate Medical Education slots
5503
Extends authorization of National Health Services Corps
5207
Teaching community health centers 5508
Innovative models in Medicare/Medicaid
3021
School-based health centers 4101
Pilot projects for emergency & trauma care
3504
Click to edit Master title styleClick to edit Master title styleGeneral Provisions (continued)General Provisions (continued)
Quality Improvement Sec.
National Strategy for Quality Improvement
3011
Quality improvement technical assistance
3501
Interagency Group on Healthcare Quality
3012
Develop, improve & evaluate quality measures
3013
Link Medicare payments to quality outcomes
3001
Pediatric Accountable Care Organizations
2706
Cost Containment Sec.
Interoperable systems of enrollment 1561
Reduce Medicaid DSH Payments 1203
Reduce Medicare DSH Payments 2551
Demonstration projects for HIT 6114
Strengthening Medicaid drug rebate programs
2501
Enhancing public program fraud screening
6401
Click to edit Master title styleClick to edit Master title styleGeneral Provisions (continued)General Provisions (continued)
Public Health & Prevention Sec.
National Prevention & Public Health Council
4001
Prevention & Public Health Fund 4002
Childhood obesity demonstration projects
4306
National diabetes prevention program
10501
New methods for scoring prevention/wellness programs
4401
Education campaign for breast cancer
10413
Social Determinants Sec.
Health Impact Assessments 4003
Community Preventative Services Task Force to review/recommend interventions in social context
4003
Community Transformation Grants 4201
Non-profit hospital community needs-assessment
9007
Primary Care Extension Program 5405
Click to edit Master title styleClick to edit Master title styleExamples of Public Health Opportunities for Advancing Health Equity through General Provisions
Examples of Public Health Opportunities for Advancing Health Equity through General Provisions
• 4001. National Prevention and Public Health Council will provide coordination and leadership at the federal level for public health and other services to consider evidence-based models, policies and innovative approaches for transformative models of public health and prevention.
• 4003. The CDC will convene an independent Community Preventive Services Task Force to review scientific evidence related to the effectiveness, appropriateness, and cost-effectiveness of community preventive interventions for the purpose of developing recommendations. Recommendations must address specific populations and social, economic and physical environments that can have broad effects on health disparities.
• 4201. The CDC is authorized to award competitive Community Transformation Grants to State and local governmental agencies and community-based organizations for the implementation, evaluation, and dissemination of evidence-based community preventive health activities to reduce chronic disease rates, prevent the development of secondary conditions, address health disparities and develop a stronger evidence-base of effective prevention programming.
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Click to edit Master title styleClick to edit Master title styleData Collection & ReportingData Collection & ReportingProvisions Section No.Require population surveys to collect racial/ethnic sub-group data 4302
Collect/report disparities data in Medicaid and CHIP 4302
Monitor health disparities trends in federally-funded programs 4302
Example of Potential Public Health Obligation and Opportunity:
4302. No later than 2 years after the date of enactment of this title, any federally conducted or supported public health program, activity or survey must collect and report data on race, ethnicity, and primary language for applicants, recipients or participants. Data must be sufficient to generate statistically reliable estimates by racial, ethnic, or primary language subgroups. In collecting these data, the OMB standards for measurement of race, ethnicity and language must be used at a minimum.
Click to edit Master title styleClick to edit Master title styleWorkforce DiversityWorkforce DiversityProvision Description Section No.
Increase diversity among health care providers 5301, 5302, 5303, 5306, 5309
Health professions training on diversity and/or CLAS 5402, 5403, 4305, 5313, 5507
Investment in HBCU and minority-serving institutions 2104
Collect and publicly report data on workforce diversity 5001
Example of Potential Public Health Obligation and Opportunity:
5303. Grants to promote public health dentistry shall give priority to applicants with experience in minority training with emphasis on cultural competence and health literacy; and who have placements in areas that serve health disparities populations.
Click to edit Master title styleClick to edit Master title styleCultural Competence (CC)Cultural Competence (CC)Provision Description Section No.
Develop, evaluate & disseminate model CC curricula 5307
CC training for health care providers 5301, 5507
Loan repayment preference for experience in CC 5203
Federal agency role and support for CC 10334
Example of Potential Public Health Obligation and Opportunity:
5307. Cultural Competency, Prevention and Public Health Grants will be established to develop, evaluate and disseminate research, demonstration projects, and model curricula for cultural competency proficiency, prevention, public health proficiency and reducing health disparities.
Click to edit Master title styleClick to edit Master title styleTable 4. Health Disparities Research Table 4. Health Disparities Research Provision Description Section No.
Patient-Centered Outcomes Research Institute (PCORI) to examine health disparities through CER
6301
Increase funding to Centers of Excellence 5401
Promote National Center for Minority Health and Health Disparities (NCMHHD) to Institute status
10334
Support research on topics disparities and cultural competence 5307, 2952, 4305
Example of Potential Public Health Obligation and Opportunity:
6301. PCORI will identify national priorities for research, addressing practice variation and health disparities in terms of delivery and outcomes of care and the potential for new evidence to improve patient health and quality of care.
Click to edit Master title styleClick to edit Master title styleTable 5. Health Disparities & PreventionTable 5. Health Disparities & PreventionProvision Description Section No.
National oral health campaign, with emphasis on disparities 4102
Standardized drug labeling on risks & benefits 3507
Maternal & child home visiting programs for at-risk pops. 2951
Culturally appropriate patient-decision aids 3506
CLAS personal responsibility education 2953
Support for preventive programs for AI/ANs 10221
Example of Potential Public Health Obligation and Opportunity:
4102. CDC will create a public education oral health campaign with a priority to address oral health disparities in a culturally and linguistically competent manner.
Click to edit Master title styleClick to edit Master title styleAddressing Disparities in Health Insurance Reforms Addressing Disparities in Health Insurance Reforms Provision Description Section No.
Remove cost-sharing for AI/ANs at or below 300% FPL 2901
Enrollment outreach targeting low-income populations 3306
CLAS/information through exchanges 1311
Nondiscrimination in federal health programs/Exchanges 1557
Require plans to provide information in "plain language” 1303
Incentive payments for reducing disparities 1303
Summary of coverage that is culturally/linguistically appropriate 1001
Claims appeal process that is culturally/linguistically appropriate 1001
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Click to edit Master title styleClick to edit Master title styleAdvancing the Health of CommunitiesAdvancing the Health of Communities
1. Leveraging support for community-based strategies and engagement in reducing disparities.
• Communities must be active and involved participants in setting overall objectives, specific goals and strategies for achieving them.
2. Promoting integrated strategies across health and social services to improve the health of diverse communities.
• Need for direct, concerted research, policy and programs that seek to alter significantly the negative influence of social determinants in diverse communities.
Click to edit Master title styleClick to edit Master title styleHealth Care Organization-Based InitiativesHealth Care Organization-Based Initiatives1. Developing and testing model programs that link specific
organizational efforts to reducing disparities and improving quality of care.
• Organizations must be committed to support practitioners through more comprehensive and active engagement in caring for diverse patients.
2. Documenting and linking non-profit community needs assessment/benefit requirements to health care reform incentives to address disparities.
• Need to reach beyond demonstrations and funding opportunities.• Require provider organizations to show evidence of working to reduce
disparities—e.g. through education & community outreach
3. Preserving and transitioning the health care safety net.• Providing direct support for safety net hospitals, particularly in regions with
large uninsured and undocumented populations.• Guidance for philanthropic organizations on ways to support safety net.
Click to edit Master title styleClick to edit Master title styleIndividual Level InitiativesIndividual Level Initiatives
1. Developing effective care/disease management and self management interventions and protocols for diverse patients.
• New programs will need to address how and to what extent inattention to race- and culture-specific and language/literacy concerns may create impediments to care management and self management.
2. Mitigating the effects of overweight/obesity and negative environmental factors that may impede progress on reducing disparities.
• Greater health care provider awareness of culture and challenges faced by diverse populations will be important for reducing disparities in care and adherence to treatment.
Click to edit Master title styleClick to edit Master title styleConclusionsConclusions• Great breadth of opportunities in ACA to reduce disparities
and improve health equity.
• However, for many provisions, depth in terms of detail, strategy for implementation, methods for implementation, and measurement/evaluation to assess progress, is still lacking.
• Allocations and federal agency roles, likewise, are unspecified for many provisions.– As of 8/1/2010, nearly two-thirds of the diversity specific provisions
lacked specificity around appropriations and timeline– About one in ten includes short term, but no long term funding plan
Click to edit Master title styleClick to edit Master title styleWhat will a new Congress mean for public health efforts to eliminate racial/ethnic disparities and
advance health equity through ACA?
Click to edit Master title styleClick to edit Master title styleNext StepsNext Steps• Education around specific ACA language for priority areas.
• Work with representative associations/organizations to educate and discuss strategies for pursuing priority areas.
• Appropriations, appropriations, appropriations—assuring adequate funding for provisions.
• Track timing and process for rollout.
• Communicate with agencies likely to oversee identified priority areas about status and progress in adding content to these areas.
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Dennis P. Andrulis, PhD, MPHSenior Research Scientist, Texas Health Institute
Associate Professor, University of Texas School of Public [email protected]
Nadia J. Siddiqui, MPHSenior Health Policy Analyst, Texas Health Institute
Jonathan P. Purtle, MPH, MScProgram Manager, Drexel University School of Public Health
Lisa Duchon, PhD, MPAHealth Management Associates
Click to edit Master title styleClick to edit Master title stylePresenter DisclosuresPresenter Disclosures
Dennis Andrulis, PhD, MPH
The following personal financial relationships with commercial interests relevant to this presentation
existed during the past 12 months:
No relationships to disclose
